SPINE Volume 31, Number 17, pp 20172023

2006, Lippincott Williams & Wilkins, Inc.

Altered Patterns of Superficial Trunk Muscle Activation

During Sitting in Nonspecific Chronic Low Back
Pain Patients
Importance of Subclassification
Wim Dankaerts, PhD,* Peter OSullivan, PhD,* Angus Burnett, PhD,* and Leon Straker, PhD*

Study Design. A cross-sectional comparative study between healthy controls and two subgroups of nonspecific
chronic low back pain (LBP) patients.
Objectives. To determine differences in trunk muscle
activation during usual unsupported sitting.
Summary of Background Data. Patients with LBP commonly report exacerbation of pain on sitting. Little evidence exists to confirm that subgroups of patients with
nonspecific chronic LBP patients use different motor patterns in sitting than pain-free controls.
Methods. A total of 34 pain-free and 33 nonspecific
chronic LBP subjects were recruited. Two blinded clinicians classified nonspecific chronic LBP patients into two
subgroups (active extension pattern and flexion pattern).
Surface electromyography (sEMG) was recorded from
five trunk muscles during subjects unsupported usual
and slumped sitting.
Results. No differences in trunk muscle activity were
observed between healthy controls and nonspecific chronic
LBP groups for usual sitting. When the classification system
was applied, differences were identified. Compared with
no-LBP controls, the active extension pattern group presented with higher levels of cocontraction of superficial fibers of lumbar multifidus (12%), iliocostalis lumborum pars
thoracis (36%) and transverse fibers of internal oblique
(43%). while the flexion pattern group showed a trend toward lower activation patterns (lumbar multifidus, 7%;
iliocostalis lumborum pars thoracis, 6%, and transverse
fibers of internal oblique, 5%). The flexion relaxation ratio
of the back muscles was lower for nonspecific chronic LBP
(superficial lumbar multifidus: t 4.5; P 0.001 and iliocostalis lumborum pars thoracis: t 2.7; P 0.001), suggesting
a lack of flexion relaxation for the nonspecific chronic LBP.
Conclusion. Subclassifying nonspecific chronic LBP
patients revealed clear differences in sEMG activity during
sitting between pain-free subjects and subgroups of nonspecific chronic LBP patients.
Key words: sitting, low back pain, subclassification,
surface electromyography. Spine 2006;31:20172023

From the *Curtin University of Technology, Perth, Western Australia;

and Department of Rehabilitation Sciences and Physiotherapy, Ghent
University, Ghent, Belgium.
Acknowledgment date: May 3, 2005. First revision date: September 14,
2005. Acceptance date: October 31, 2005.
This study was carried out while the first author (W.D.) was an International Postgraduate Research Scholar in Australia and was supported financially by the Head of School of Physiotherapy Scholarship,
Curtin University of Technology Western Australia.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Federal and Institutional funds were received in support of this work.
No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Wim Dankaerts, School
of Physiotherapy, Curtin University of Technology, GPO Box U1987,
Perth, Western Australia; E-mail: W.Dankaerts@exchange.curtin.edu.au

The increasing cost and disability relating to chronic low

back pain (CLBP) is well documented.1 Despite the large
number of pathologic conditions that give rise to CLBP,
85% of this population is classified as having nonspecific CLBP as no radiologic abnormality is detected.2
Previous research has examined the function of the
trunk muscles by means of surface electromyography
(sEMG) amplitude in both controls and low back pain
(LBP) subjects.3,4 There is considerable evidence suggesting dysfunction of the neuromuscular system in the presence of nonspecific CLBP, although the nature of the
dysfunction is highly variable. During static tasks, such
as standing, inconsistent levels of trunk muscle activation in CLBP populations have been found. Specifically,
CLBP subjects have been reported to have increased,3,5
decreased,6,7 and similar6,8 sEMG amplitudes compared
with controls. These contradictory results may reflect the
heterogeneity of the nonspecific CLBP group, which is
proposed to conceal different subgroups.9,10
Sitting is commonly reported to exacerbate and perpetuate LBP.1113 The sparse research into muscle activity in
sitting and LBP, suggests no difference in the sEMG amplitude of LBP compared with controls, and large variability
in raw values.14 In contrast, based on clinical observation,
OSullivan15 described that during sitting nonspecific CLBP
patients with a flexion pattern (FP) disorder posture themselves in end-range flexion and have reduced cocontraction
of the lumbo-pelvic stabilizing muscles, while patients with
an active extension pattern (AEP) disorder hold themselves
actively into hyperextension.
Despite the known importance for classifying patients
with nonspecific CLBP,9,10 and clinical reports15 suggesting differences based on subgrouping, no studies
have reported trunk muscle activation patterns in sitting
for specific subgroups of nonspecific CLBP.
Research evaluating the function of paraspinal muscles
during spinal flexion has been more successful in identifying LBP patients from healthy controls. These studies suggest that LBP patients typically lack the flexion relaxation
phenomenon, a period of myoelectrical silence of the back
muscles when an individual stands in full flexion.16 19
Interestingly, despite its demonstrated discriminative
validity in standing-flexion, the increase in sedentary lifestyle and the reported link between LBP and sitting, the
flexion relaxation phenomenon has not been widely investigated during sitting. The available studies, on flexion relaxation phenomenon of the back muscles in sitting
have reported on a no-LBP population only.20,21
2017

2018 Spine Volume 31 Number 17 2006

Therefore, the objectives of the present study were to

determine whether a difference exist between the trunk
muscle activation patterns of healthy controls and CLBP
subjects during usual unsupported sitting, to investigate
the flexion relaxation phenomenon in sitting (by comparing usual sitting to slumped sitting) and finally to
investigate the importance of classifying the nonspecific
CLBP population into homogenous subgroups.
Methods
Participants. Sixty-seven volunteers (33 nonspecific CLBP patients and 34 controls) were recruited from the Perth metropolitan area. The Human Research Ethics Committee, Curtin University of Technology approved the study. All subjects
provided written informed consent before testing. Control subjects were sampled on convenience and consisted of students,
relatives of students and personnel affiliated with the University. They were excluded from the study if they had a history of
LBP or leg pain over the previous 2 years and/or had received
previous postural education. Nonspecific CLBP patients were
recruited from a private orthopedic clinic.
Nonspecific CLBP patients were blindly assessed by two
musculoskeletal physiotherapists (W.D. and P.O.), based on a
subjective and physical examination.15 The comprehensive history of the disorder involved: screening for psychosocial yellow flags (identification of beliefs, emotions and behaviors
that interact with the pain problem)22 and red flags (specific
causes of LBP such as cauda equina syndrome or inflammatory
disease),23 reviewing medical imaging, questioning the patient
regarding symptom provocation and relief. The full physical
examination consisted of a series of active and functional
movement tests, articular tests to determine mobility and level
of symptom provocation, neurologic examination, and tests for
spinal motor control.15 Both assessments took place in a private orthopedic clinic in the Perth metropolitan area. There
was a maximum of 1 week between both examinations and the
laboratory testing. Only patients presenting with a clinical presentation of a FP or AEP disorder as determined independently
by both clinicians were selected for this study. Previous research has identified that these subgroups can be reliably identified by trained clinicians (physiotherapists and medical physicians).24 Table 1 presents the strict inclusion/exclusion
criteria and a summary of clinical features of the two clinical
patterns. Subjects characteristics are shown in Table 2.

Experimental Protocol. Synchronized recordings of the activation (sEMG) of ten superficial trunk muscles were obtained
for each subject during two sitting conditions: usual and
slumped sitting. Usual sitting was defined as the sitting posture subjects would usually adopt during unsupported sitting.
Slumped sitting was defined as sitting in an attempt to fully
relax and slouch the spine. Three trials of five seconds duration
each were conducted, with approximately 1-minute rest between each trial.
Each participant sat on a stool (with no back support) with
a flat, horizontal surface. The height of the stool was adjusted
to ensure that the participants upper legs were horizontal and
the lower legs vertical. The feet were positioned shoulder width
apart with arms hanging relaxed next to the thighs. Participants viewed a visual target set 1.5 m in front of the participants, at eye level to standardize the head posture.

Table 1. Inclusion and Exclusion Criteria

Inclusion criteria for nonspecific CLBP with motor control impairment of
flexion pattern (FP) or active extension pattern (AEP)
3 months nonspecific LBP
Revised Oswestry score 15%
Pain localized to the lower lumbar spine (L4L5 or L5S1) region
Absence of red flags (specific causes of LBP such as cauda
equina syndrome or inflammatory disease)
Absence of dominant yellow flags (identification of beliefs,
emotions, and behaviors that interact with the pain problem)
Clear mechanical basis of disorder
Associated impairments in the control of the motion segment(s) in
the provocative movement direction(s)
Absence of impaired movement of the symptomatic segment in the
painful direction of movement or loading (based on clinical joint
motion palpation examination)
Clinical diagnosis of an FP or AEP disorder, both clinicians
(independently) agreed upon the diagnosis
Key clinical features of FP
Aggravation of symptoms with movements and postures involving
flexion of the lower lumbar spine
Loss of segmental lordosis at symptomatic level, difficulty assuming
and/or maintaining neutral lordotic postures with a tendency to flex
lower lumbar spine
Pain relief with spinal extension
Key clinical features of AEP
Aggravation of symptoms with movements and postures involving
extension of the lower lumbar spine
Excess of segmental lordosis at symptomatic level with posture
and movements
Difficulty assuming and/or maintaining neutral lordotic postures
with a tendency to position themselves into hyperextension
Pain relief with spinal flexion
Exclusion criteria for nonspecific CLBP with motor control impairment of
FP or AEP
Previous spine surgery, pregnant at the time of the study or 6
months postpartum, recently undergone a period of motor control
rehabilitation
Not fulfilling inclusion criteria

Data Collection and Management

sEMG. Ten channels of sEMG data were sampled using two
8-channel Octopus Cable Telemetric systems (Bortec Electronics Inc., Calgary, Canada) at 1,000 Hz, bandwidth was 10 to
500 Hz, common mode rejection ratio was 115 dB at 60 Hz.
All raw myoelectric signals were preamplified and amplified
with an overall gain of 2000. Data were collected on a computer running LabVIEW V6.1 (National Instruments). Pairs of
self-adhesive disposable Ag/AgCl (Red Dot, 3 M Health Care

Table 2. Characteristics of Subjects per Group

Gender
Males
Females
Age (yr)
Weight (kg)
Height (m)
BMI (kg/m2)
R-Oswestry (%)
Pain duration (yr)

No-LBP
Controls
(n 34)

Flexion
Pattern
(n 20)

Active
Extension
Pattern
(n 13)

18 (53%)
16 (47%)
32.0 (12.2)
68.4 (11.6)
1.71 (0.09)
23.3 (2.9)

16 (80%)
4 (20%)
35.7 (11.2)
80.1 (10.6)
1.8 (0.1)
24.6 (2.5)
36.6 (11.0)
4.9 (5.3)

5 (38.5%)
8 (61.5%)
39.9 (11.3)
72.8 (15.7)
1.70 (0.1)
24.2 (2.8)
41.2 (14.2)
7.4 (5.3)

Group
Differences
Significant
*

BMI body mass index; LBP low back pain.

Values are average (%) or average (SD).
*P 0.05.

*
*

Trunk Muscle Activation Dankaerts et al 2019

Products, London, Ontario, Canada) disc surface electrodes
with an electrical contact surface of 1 cm2 were placed parallel
to the muscle fibers with a center-to-center spacing of 2.5 cm.
Snap leads were used to connect the surface electrodes to the
preamplifiers. Skin preparation for sEMG was according to
Hermens et al.25
Pairs of surface electrodes were bilaterally positioned of
three abdominal and three back muscles.
Rectus abdominis (RA): 1 cm above the umbilicus and 2 cm
lateral to the midline.26
External oblique (EO): just below the rib cage and along a
line connecting the most inferior point of the costal margin
and the contralateral pubic tubercle.26
Transverse fibers of internal oblique (TrIO): 1 cm medial to
the anterior superior iliac spine (ASIS) and beneath a line
joining both ASISs.26
Superficial fibers of lumbar multifidus (sLM): at L5 and
aligned parallel to the line between the posterior superior
iliac spine (PSIS) and the L1L2 interspinous space.27
Iliocostalis lumborum pars thoracis (ICLT): above and below the level of L1 spinous process midway between the
midline and the lateral aspect of the body.28
Since two telemetric systems were used, two common earth
electrodes were placed over the left iliac crest.

Before processing the raw sEMG data, a customized program in conjunction with visual inspection was used to
detect and eliminate possible contamination by heartbeat and other artifacts. Raw data were then demeaned,
full-wave rectified, and band pass filtered (4 Hz and 400
Hz) using a fourth order zero lag Butterworth filter,29
and a linear envelope was calculated for each channel.
sEMG measurements were amplitude normalized to
two standardized activities designed to elicit a stable submaximal voluntary isometric contraction (sub-MVIC).
These normalization procedures have shown to be reliable both within-day and between-day.30
Sub-MVIC normalized muscle activation for usual
and slumped sitting was averaged across the three trials
for each subject. Finally, flexion/relaxation ratio31 in sitting was calculated by dividing the average sEMG in
usual sitting by the average activity in slumped sitting.

comparisons (Bonferroni) was used to compare the differences

between the No-LBP, FP, and AEP groups. Paired t tests were
performed to compare differences between usual and slumped
within each group. SPSS V11.5 (SPSS Chicago, IL) was used to
perform all statistical tests and the alpha level was set at 0.05.

Results
Statistical analyses were performed for left and right
sides. There were no differences; hence, we provided results from one randomly picked side (left). The mean and
standard deviation of the muscle activation (percentage
of sub-MVIC) for usual sitting, slumped sitting are presented in Figures 1 and 2 per muscles and per sitting
condition for all groups (CLBP pooled/classified). All
group comparisons and their statistical differences are
listed in Table 3.
No-LBP Versus Nonspecific CLBP (Pooled)
Back Muscles. There was no difference in activity of
sLM [t 0.1, P 0.909] and ICLT [t 1.3, P
0.207] between the No-LBP and nonspecific CLBP
(pooled) groups in usual sitting. However, there was
greater back muscle activity in the nonspecific CLBP patients (pooled) in slumped sitting [sLM: t 3.4, P
0.001 and ICLT: t 2.8, P 0.006].
Abdominal Muscles. No differences were observed for
the abdominal muscles between No-LBP and nonspecific

Reliability of the Measurements. Reliability of the measurement methods was assessed using an intraclass correlation coefficient [(3,1)] and the standard error of measurement.32 The
intertrial reliability of all sEMG measurements was excellent.
Intraclass correlation coefficient values ranged between 0.87
and 0.99. The standard error of measurement ranged from
0.05 to 0.18 (% of sub-MVIC).

Statistical Analysis
All underlying assumptions to use parametric statistics were
tested (using Levenes Test for Equality of Error variance) and
found valid. To assess for group differences 2 was used for
nominal data (gender and age) and ANOVA for weight, height
and body mass index.
Independent t tests were used to compare the differences in
sEMG activity between the no-LBP and nonspecific-CLBP
(pooled) groups. Further, a one-way ANCOVA with post hoc

Figure 1. Mean and standard deviation (error bars) of the back

muscle activation per muscles and per sitting condition for all
groups (nonspecific CLBP pooled/classified). sLM superficial
lumbar multifidus; ICLT iliocostalis lumborum pars thoracic.

2020 Spine Volume 31 Number 17 2006

Figure 3. The mean and standard deviation (error bars) for the
Flexion Relaxation Ratio for the back muscles and for each subgroup. sLM superficial lumbar multifidus; ICLT iliocostalis
lumborum pars thoracic.

6.6; P 0.003; ICLT: F2,64 9.9; P 0.001], when

compared with No-LBP and FP.

Figure 2. Mean and standard deviation (error bars) of the abdominal

muscle activation per muscles and per sitting condition for all groups
(nonspecific CLBP pooled/classified). TrIO transverse fibers internal oblique; EO external oblique; RA rectus abdominis.

CLBP (pooled) for usual [TrIO: t 1.0, P 0.305;

EO: t 0.3, P 0.758;RA: t 1.0, p.306], and
slumped sitting [TrIO: t 1.4, P 0.163; EO: t
0.6, P 0.536; RA: t 1.4, P 0.167].
No-LBP Versus AEP and FP
Back Muscles. AEP showed higher back muscles activity in usual [sLM: F2,64 5.5; P 0.006; ICLT: F2,64
12.58.9; P 0.001] and slumped sitting [sLM: F2,64

Abdominal Muscles. The activity of TrIO of AEP was

higher, compared with No-LBP and FP in usual [F2,64
4.2; P 0.019] and slumped [F2,64 5.1; P 0.009]
sitting. No differences were noted for EO [F2,64 0.6;
P 0.527] and RA [F2,64 2.3; P 0.106] during usual
sitting or slumped sitting [EO: F2,64 0.4; P 0.661;
RA: F2,64 3.0; P 0.06].

Flexion Relaxation Ratio in Sitting

The mean and standard deviation for the flexion relaxation ratio of the back muscles is presented in Figure 3.
The independent t test showed a significant difference in
the FRR for both the sLM [t 4.6; P 0.001] and ICLT
[t 2.7; P 0.001] between no-LBP and nonspecific
CLBP (pooled). Post hoc Bonferroni testing did not reveal any difference between the AEP and FP subgroups
(sLM: F 10.28; P 0.001; FP AEP no-LBP and
ICLT: F 3.83; P 0.03; FP AEP no-LBP).

Table 3. Results for Back and Abdominal Muscles for Each Sitting Condition
No-LBP vs. FP vs. AEP

No-LBP vs.
NS-CLBP:
Independent t Test

Back muscles

Usual
Slumped

Abdominal muscles

Usual
Slumped

ANCOVA

Muscle

sLM
ICLT
sLM
ICLT
TrIO
EO
RA
TrIO
EO
RA

0.11
1.27
3.39
2.82
1.03
0.30
1.03
1.41
0.62
1.39

0.909
0.207
0.001*
0.006*
0.31
0.76
0.31
0.16
0.54
0.17

5.5
8.9
6.6
9.9
3.2
0.9
2.3
3.4
0.1
2.3

0.006*
0.001*
0.003*
0.001*
0.04*
0.37
0.11
0.04*
0.92
0.10

Post Hoc Bonferroni

FP
FP
NO
NO
FP
FP
NO
FP
NO
NO

NO
NO
FP
FP
NO
NO
FP
NO
FP
FP

AEP
AEP
AEP
AEP
AEP
AEP
AEP
AEP
AEP
AEP

No-LBP no low back pain; NS-CLBP nonspecific chronic low back pain; FP flexion pattern; AEP active extension pattern; sLM superficial lumbar
multifidus; ICLT iliocostalis lumborum pars thoracic; TrIO transverse fibers internal oblique; EO external oblique; RA rectus abdominis.
EMG activity is ranked (from lowest to highest) underlined group data links those that do not significantly differ.
*Significant (P 0.05).

Trunk Muscle Activation Dankaerts et al 2021

Difference Between Usual and Slumped Sitting in

Superficial Lumbar Multifidus Activity
When subjects with a FP moved from usual sitting to
slumped sitting they showed a nonsignificant increase in
sEMG (4%; t 1.6; P 0.11) of the sLM (at the
level of their LBP). Similar, the AEP subjects did not show a
difference in sLM muscle activity when compared with
usual upright sitting (37% vs. 36%; t 0.42; P
0.685). In contrast the no-LBP group showed a clear
difference (23% vs. 14%; t 4.4; P 0.001) suggesting
a relaxation response.
Discussion
This study found no differences in superficial trunk muscle activation patterns between healthy controls and
nonspecific-CLBP (pooled) subjects during usual sitting.
These findings are in agreement with several studies that
have reported no differences in trunk muscle function
during different posture and stress tasks in CLBP versus
control subjects.5,8,33,34 In contrast, other studies have
reported that CLBP subjects have increased3,5 or decreased6,7 muscle sEMG amplitude.
The results of this study support the literature reporting the inherent heterogeneity of the CLBP population.9,10,11 Indeed, when the nonspecific CLBP patients
were subclassified, this study showed that in the AEP
subgroup, CLBP was associated with increased levels of
muscle coactivation for sLM, ICLT, and TrIO compared
with the No-LBP and FP groups. These experimental
findings are consistent with the clinical classification of
AEP based on OSullivans classification system.15,35
The above findings represent a washout effect36 when
nonspecific CLBP patients are pooled, where the findings in
one subgroup of patients is washed-out by the opposite
findings in another subgroup. This clearly highlights the
importance of defining specific subgroups and developing a
clinically meaningful classification system for the nonspecific CLBP. This has been ranked as a top research priority
for several years, although limited progress has been made
in its development and application.9,37
The difference between no-LBP and LBP in flexion
relaxation ratio for the back muscles (Figure 3) reflects
an absence of relaxation (AEP) and increased activity
(FP) in the sLM and ICLT during slumped sitting versus
a clear reduction in the no-LBP group (Figure 1). This
latter finding is consistent with OSullivan et al21 who
demonstrated in no-LBP subjects that slumped sitting
was associated with a period of myoelectrical silence of
the trunk muscles. The absence of flexion relaxation in
the nonspecific CLBP patients in this study is consistent
with studies examining flexion relaxation in upright
standing in back pain populations.16 19
This study clearly shows that there is not a homogeneous trunk muscle activation pattern in the nonspecific
CLBP population identified during sitting. These results
may reflect two different underlying mechanisms to the
LBP disorder.

Flexion Pattern
The average back muscle activity during usual sitting in
the FP patients (17%) was nonsignificantly less when
compared with the no-LBP subjects (24%) (P 0.27).
This was associated with sitting with a flexed lower lumbar spine as reported by Dankaerts et al.38 Since all FP
subjects reported pain after prolonged sitting, it is hypothesized that this pattern of decreased muscular activation in association with increased lumbar spine flexion
in this FP group38 may produce mechanical stress into
flexion leading to LBP.39 41
The nonsignificant trend (P 0.11) of increased muscle activation, when actually asked to relax (moving
from usual sitting to slumped sitting), was only seen in
the sLM (local to the symptomatic region) of the FP
patients, and it was linked with the direction of pain
provocation (flexion) reported by these subjects. While
the range of motion into flexion was similar to the controls,38 this represented a difference in motor response.
This increase in muscle activity seen in the FP group is
consistent with a ligamento-muscular protective reflex at
end range of lumbar spine flexion as reported by
Solomonow et al.39,40,42,43
Active Extension Pattern
In contrast with the FP group and controls, hyperactivity was demonstrated in the back muscles and TrIO of
the AEP patients. This was associated with a hyperlordotic posture38 and subjectively reported extension related pain. Of importance is that these subjects did not
report pain at time of testing, suggesting that this motor
pattern was not directly driven by pain.
When asked to slump, the AEP subjects showed a lack
of flexion relaxation (at the level of their LBP) when
compared with usual upright sitting (37% vs. 36%; t
0.42; P 0.685). While it is not clear from the results
why the AEP subjects present in this manner (despite
slumping is a movement away from their direction of
pain provocation), the observed hyper-activity coactivation pattern of this group associated with hyperlordosis38 may prevent motion and impose substantial
extension load penalties on the lumbar spine, which may
perpetuate LBP.44 46
These findings, in both FP and AEP patients, appear to
represent maladaptive postural patterns with the potential to provoke strain and pain.
A number of limitations of this study need to be highlighted. The authors acknowledge that the strict inclusion/
exclusion criteria applied limit the generalizability of the
results for the whole LBP population. This study only examined a very short duration of sitting; therefore, the effects
of prolonged sitting on trunk muscle activation are unknown and future studies will investigate this. The results
of this study are limited to the superficial muscle sites under
examination; therefore, future work should focus on the
involvement of deeper muscles deemed important in LBP,
such as quadratus lumborum and psoas, the deep fibers of
sLM, and the transverses abdominis.47,48

2022 Spine Volume 31 Number 17 2006

Implications for Clinical Practice and Research

The results of this study may have important implications for therapeutic management and LBP research in
subjects with nonspecific CLBP where sustained sitting
postures are reported to be a primary aggravating factor.
Identifying a subgroup (AEP) with increased cocontraction of local stabilizing muscles is important clinically. For the AEP subgroup, a rehabilitation approach
that focuses more on the inhibition of the dominant activation of these muscles while posturing the spine within
a more neutral lordosis seems to be more appropriate.15
In this study, usual unsupported sitting in the healthy
controls required low muscle activity while a neutral
lumbar spine was adopted.38 In contrast, there was a
trend of decreased muscle activity in FP patients, accompanied with an increase in lumbar flexion.38 It can be
speculated that a logical approach for rehabilitation of
these subjects would involve facilitation of neutral lordotic postures while facilitating low level muscular coactivation of the local spinal stabilizing muscles.15,47 Randomized controlled trials are required to investigate if
this approach would show a reduction in pain and disability in these LBP populations.
Finally, the results of this study may also have implications for LBP research. The heterogeneity of the nonspecific CLBP population highlights the importance for
defining specific subgroups. Improved research methods,
incorporating clinically meaningful classification systems for this population, will enhance the value of the
results and prevent washout.
Key Points
Differences in muscular activity (as measured by
sEMG) were studied in healthy controls and nonspecific CLBP patients during sitting.
No differences were found during usual sitting
when the nonspecific CLBP patients were pooled.
Analysis based on subgrouping the patients revealed significant differences in muscle activation
patterns and highlights the importance of subclassifying nonspecific CLBP patients.
These differences in muscle activation pattern appear to represent maladaptive postural patterns with
the potential to provoke strain and pain. They may
reflect two different underlying mechanisms for
CLBP during sitting.
The results of this study may have important implications for therapeutic management and LBP research in subjects with nonspecific CLBP where
sustained sitting postures are reported to be a primary aggravating factor.

Acknowledgments
The authors thank Paul Davey (research assistant) and Dr.
Ritu Gupta (statistician) of Curtin University of Technology for their kind assistance throughout this study.

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